Impact of a correct breathing stereotype on pulmonary minute ventilation, blood gases and acid-base balance in post-myocardial infarction patients

STUDY OBJECTIVE

The aim of the study was to evaluate the impact of a long-term (6-month) correct breathing stereotype on minute ventilation, capillary blood gases and acid-base balance in post-myocardial infarction patients.

METHODS

Fifty-five men (age 57.2 +/- 12.5) were examined 2 months later after myocardial infarction. Spirometry and assessment of acid-base balance and capillary blood gases were performed at rest and repeated after 10 days and 6 months. Breathing correction was taught over 5 days. A session for the control and maintenance of the correct breathing skills was hosted once a month (during the 6-month period).

RESULTS

Changes of minute ventilation, capillary blood gases and acid-base balance were revealed in 55% of patients 2 months later after myocardial infarction. Twenty patients (group I) were randomly selected for breathing correction while 10 patients made up the control group (group II). After breathing correction minute ventilation significantly decreased (18.5 +/- 5.5 versus 9.8 +/- 2.5 l/min), oxygen ventilatory equivalent decreased (39.8 +/- 5.2 versus 22.5 +/- 3.8), partial pressure of blood carbon dioxide increased (33.2 +/- 1.7 versus 44.2 +/- 2.5 mmHg), plasma bicarbonate concentration augmented (19.1 +/- 2.2 versus 24.5 +/- 1.8 mmol/l), base excess normalized (-2.90 +/- 2.5 versus +1.3 +/- 2.1 mmol/l), and pH shifted to more alkaline value (7.36 +/- 0.01 versus 7.43 +/- 0.02).

CONCLUSIONS

A long-term correct breathing stereotype improved respiratory function and could be an additional measure in rehabilitation programmes for post-myocardial infarction patients.

Impact of hypertension on postreperfusion left ventricular recovery in patients with ST-segment elevation myocardial infarction and multivessel coronary artery disease

OBJECTIVE

The aim of this study was to investigate the impact of admission systolic blood pressure (ASBP) and left ventricular (LV) mass on the postreperfusion LV recovery in patients with ST-segment elevation myocardial infarction (STEMI) and concomitant coronary multivessel disease (MVD).

MATERIALS AND METHODS

A retrospective analysis of 12-month postreperfusion LV recovery was performed in 104 patients after primary percutaneous coronary intervention (PPCI). Patients with elevated ASBP (>140mmHg) were assigned to the first group (n=58); with normal ASBP (<140mmHg), to the second group (n=46); with increased myocardial mass index (MMI) (>100g/m(2)), to the third group (n=70); and with normal MMI (<100g/m(2)), to the fourth group (n=34). Severity of MVD was evaluated by the Syntax score. The LV recovery was assessed by evolution of quantitative characteristics of electrocardiography (QRS score, ST score, ECG STEMI stage) and echocardiography (LV ejection fraction, volume and mass indices) registered before and after PPCI, at discharge, and after 1, 6, and 12 months.

RESULTS

There were no significant differences in the baseline QRS and ST scores, ECG STEMI stage, LVEF, MMI, and Syntax score comparing all the patients' groups. The serial ECG criteria showed only a very small impact of ASBP on postreperfusion LV recovery. Only ECG STEMI stage progression was slower in the patients with elevated ASBP. In patients with different MMI, the QRS and ST scores were higher and ECG STEMI stage was lower in patients with increased MMI. LVEF after 1 year was significantly lower in the third group as compared to the fourth group (42.58%±8.25% vs. 46.8%±7.13%, P=0.018).

CONCLUSION

Postreperfusion LV recovery was more related not to ASBP but to the increased LV mass assessed by echocardiography in patients with STEMI and MVD.

Effectiveness of a new exercise program after lower limb arterial blood flow surgery in patients with peripheral arterial disease: a randomized clinical trial

OBJECTIVE

The aim of this study was to evaluate the effectiveness of a supervised exercise program (SEP) plus at home nonsupervised exercise therapy (non-SET) on functional status, quality of life (QoL) and hemodynamic response in post-lower-limb bypass surgery patients.

RESULTS

One hundred and seventeen patients were randomized to an intervention (n = 57) or a control group (n = 60). A new individual SEP was designed for patients with peripheral arterial disease (PAD) and applied to the studied subjects of the intervention group who also continued non-SET at home, whereas those assigned to the control group received just usual SEP according to a common cardiovascular program. The participants of the study were assessed by a 6-min walking test (6 MWT), an ankle-brachial index (ABI), and the Medical Outcomes Study Short Form-36 (SF-36) of QoL at baseline, at 1 and 6 months after surgery. A significant improvement was observed in the walked distance in the intervention group after 6 months compared with the control group (p < 0.001). The intervention group had significantly higher QoL score in the physical and mental component of SF-36 (p < 0.05).

CONCLUSIONS

A 6-month application of the new SEP and non-SET at home has yielded significantly better results in walking distance and QoL in the intervention group than in the controls.

Strongmen sport is associated with larger absolute heart size and impaired cardiac relaxation

This study was carried out to compare cardiac structure and function and blood lipids among Strongmen, sedentary controls, and marathoners. Echocardiography was performed, and endothelial function, blood lipids and maximal oxygen uptake were measured in 27 Caucasian adult men (8 Strongmen, 10 marathoners, 9 controls). Absolute cardiac size parameters such as left ventricular (LV) diameter and wall thickness of Strongmen were higher (p < 0.05), but relative (body surface area indexed) parameters were not different between controls and Strongmen. In Strongmen, the relative LV diameter (p < 0.05), wall thickness (p < 0.001), and LV mass index (p < 0.01) were lower than in marathoners. The absolute but not relative right ventricular diameter was larger in Strongmen as compared with controls, whereas all of the measured relative cardiac size parameters were higher in marathoners as opposed to in controls. The endothelial function and the ratio of wall thickness to chamber diameter were similar among the groups (p > 0.05). Maximal oxygen uptake of Strongmen was lower than in controls (p < 0.05) and marathoners (p < 0.001). Global diastolic LV function of Strongmen was impaired in comparison to controls (p < 0.05) and marathoners (p < 0.05). Plasma lipids were not different between Strongmen and sedentary controls, but in comparison to runners, Strongmen had higher low-density lipoprotein-cholesterol (p < 0.05) and lower high-density lipoprotein cholesterol (p < 0.01). Participation in Strongmen sport is associated with higher absolute but not relative cardiac size parameters, impaired myocardial relaxation, and low cardiorespiratory fitness. Therefore, Strongmen may demand greater attention as an extreme group of athletes with regard to cardiovascular risk.

The impact of complex cardiac rehabilitation on manifestation of risk factors in patients with coronary heart disease

BACKGROUND

Each year more than 4.3 million people in Europe will die of cardiovascular disease. Therefore, the implementation of simple interventions such as smoking cessation, weight loss, improved diets, and increased exercise is the top priority in prevention and rehabilitation programs. The aim of this study was to evaluate the impact of complex rehabilitation on the manifestation of risk factors and cardiac events in patients with coronary heart disease.

MATERIAL AND METHODS

A total of 140 patients with coronary heart disease and NYHA functional class II-IV ischemic heart failure were recruited to the study. The patients were divided into 2 groups: 70 patients who underwent a 6-month complex rehabilitation course (rehabilitation group) and 70 patients who received drug treatment only (control group). Smoking, dietary, and physical activity habits were documented using the questionnaires. Blood pressure (BP), body weight and height, and total serum cholesterol, low-density lipoprotein (LDL) cholesterol, high-density lipoprotein (HDL) cholesterol, triglyceride (Tg), and blood glucose levels were measured. Measurements were repeated after 3 and 6 months.

RESULTS

After 6 months, significantly reduced systolic BP was observed in both the groups as compared with the baseline values (P<0.05). A significant decrease in the diastolic BP; total cholesterol, LDL-cholesterol, triglyceride and blood glucose levels; body mass index, and percentage of patients with the metabolic syndrome as compared with the baseline data was documented only in the rehabilitation group (P<0.05). All the patients quitted smoking as well as all the patients in the rehabilitation group changed their dietary habits (P<0.05). Fewer patients were excluded from the rehabilitation group because of cardiac events as compared with the control group (7.1% vs. 11.4%, P<0.05).

CONCLUSIONS

Complex long-term rehabilitation of cardiovascular patients significantly reduced the manifestation of major cardiovascular risk factors and the rate of cardiac events. Aerobic exercise must be the most important part of training but well-done resistance training must also be encouraged.

[The effectiveness of long-term rehabilitation in patients with cardiovascular diseases]

BACKGROUND

Screening results of EuroAspire III study have revealed the failure of effective correction of cardiovascular risk factors in all 22 participating EU countries. How long should cardiac rehabilitation programs last to impact motivation for lifestyle change?

AIM AND OBJECTIVES

To compare the impact of long-term (6 months) rehabilitation versus short-term (4 weeks) rehabilitation on the reduction of risk factors and cardiac events, as well as on the use of cardioprotective drugs.

METHODS

Study contingent of 150 patients, suffering from functional class III-IV (NYHA) chronic heart failure caused by ischemic and hypertensive cardiomyopathy, was subjected to complex rehabilitation: exercise training, dietary corrections, and smoking cessation. The patients were divided into two groups: long-term rehabilitation group (n=80) and short-term rehabilitation group (n=70). Blood pressure, body mass index, dietary habits, dyslipidemia, sedentary lifestyle, smoking, chronic fatigue, and use of cardioprotective drugs were evaluated in all patients at the onset of study, after 4 weeks, and 6 months. Cardiovascular events were estimated throughout the whole 6-month period.

RESULTS

In the long-term rehabilitation group, there was a significant reduction (P<0.05) in systolic blood pressure (151+/-9.2 vs. 135+/-9.7 mm Hg), diastolic blood pressure (92.3+/-6.5 vs. 75.4+/-3.8 mm Hg,) body mass index (35.4+/-3.5 vs. 27.2+/-4.8 kg/m(2)), dyslipidemia (56.3 vs. 23.4%), sedentary lifestyle (31.3 vs. 4.7%), and smoking (10.0 vs. 0%). The impact of a short-term rehabilitation was not significant. Because of cardiac events, 13 patients (16.3%) in the long-term rehabilitation group and 26 (16.3%) in the short-term rehabilitation group failed to complete the 6-month study (P<0.05). The following change in drug use pattern was noted in the long-term rehabilitation group: nitrates, 74 vs. 65%; digitalis, 42 vs. 32%; antiarrhythmic agents, 15 vs. 10%; statins, 36 vs. 20% (P<0.05). During 6 months, in both groups, because of better physician monitoring, there was no decrease in the use of major cardioprotective drugs, such as antiaggregants, beta-blockers, and ACE inhibitors.

CONCLUSIONS

Long-term (6 months) versus short-term (4 weeks) rehabilitation of cardiovascular patients significantly reduces manifestation of major cardiovascular risk factors, the rate of cardiac events, chronic fatigue and improves the use of cardioprotective drugs.

[Evaluation of a chronic fatigue in patients with moderate-to-severe chronic heart failure]

THE AIM OF THE STUDY

To evaluate the chronic fatigue and its relation to the function of hypothalamus-pituitary-adrenal axis in patients with New York Heart Association (NYHA) functional class III-IV chronic heart failure.

MATERIAL AND METHODS

A total of 170 patients with NYHA functional class III-IV chronic heart failure completed MFI-20L, DUFS, and DEFS questionnaires assessing chronic fatigue and underwent echocardiography. Blood cortisol concentration was assessed at 8:00 am and 3:00 pm, and plasma N-terminal brain natriuretic pro-peptide (NT-proBNP) concentration was measured at 8:00 am. Neurohumoral investigations were repeated before cardiopulmonary exercise test and after it.

RESULTS

The results of all questionnaires showed that 100% of patients with NYHA functional class III-IV heart failure complained of chronic fatigue. The level of overall fatigue was 54.5+/-31.5 points; physical fatigue - 56.8+/-24.6 points. Blood cortisol concentration at 8:00 am was normal (410.1+/-175.1 mmol/L) in majority of patients. Decreased concentration was only in four patients (122.4+/-15.5 mmol/L); one of these patients underwent heart transplantation. In the afternoon, blood cortisol concentration was insufficiently decreased (355.6+/-160.3 mmol/L); reaction to a physical stress was attenuated (Delta 92.9 mmol/L). Plasma NT-proBNP concentration was 2188.9+/-1852.2 pg/L; reaction to a physical stress was diminished (Delta 490.3 pg/L).

CONCLUSION

All patients with NYHA class III-IV heart failure complained of daily chronic fatigue. Insufficiently decreased blood cortisol concentration in the afternoon showed that in the presence of chronic fatigue in long-term cardiovascular organic disease, disorder of a hypothalamus-pituitary-adrenal axis is involved.

[Return to work after coronary artery bypass surgery]

The aim of this study was to assess the possible reasons for not returning to work after coronary artery bypass surgery. A total of 134 patients (aged 65 years and younger) who underwent coronary bypass surgery in 2003 were examined. The analysis was performed in three groups of the patients: Group I, patients who were employed before surgery and returned to work after it (n=51); Group II, patients who were employed before surgery but did not return to work after surgery (n=55); and Group III, patients who were unemployed before and remained unemployed after surgery due to health problems (n=28). Number of injured coronary arteries, the extent of operation, postoperative complications, risk factors for ischemic heart disease, clinical status of patients (angina pain and heart failure), physical tolerance, and return to work within one year after coronary bypass surgery were analyzed. It was found that 48.1% of patients who were employed before surgery returned to work after myocardial revascularization. About 30% of patients experienced recurrent symptoms of angina after 12 months. Logistic regression analysis revealed that return to work was significantly influenced by female gender, physical pattern of work, age, and severity of heart failure.

[Impact of a long-term complex rehabilitation on chronic fatigue and cardiorespiratory parameters in patients with chronic heart failure]

The aim of the study was to evaluate the impact of a long-term rehabilitation on chronic fatigue and cardiorespiratory parameters in patients with chronic heart failure.

MATERIAL AND METHODS

One hundred seventy patients with class III-IV (NYHA) chronic heart failure were examined. The study population was divided into two groups: long-term rehabilitation group and control group. They underwent cardiopulmonary exercise test and completed questionnaires on chronic fatigue (MFI-20L, DUFS, and DEFS). Measurements were repeated 3 and 6 months after long-term complex rehabilitation.

RESULTS

According to the data of MFI-20L, DUFS, and DEFS questionnaires, 170 patients (100%) with class III-IV (NYHA) chronic heart failure complained of fatigue. Overall daily fatigue was 56.8+/-28.5 points on a 100-point scale, and after 6-month rehabilitation, this parameter was statistically significantly reduced on all scales (P<0.05). Physical fatigue and self-care improved in controls. Cardiopulmonary exercise test showed that parameters of hyperventilation, ventilatory equivalents, and pCO2 were significantly improved in rehabilitation group after 6 months as compared to baseline data (P<0.05), but not in the control group.

CONCLUSION

Patients with class III-IV (NYHA) chronic heart failure experience chronic fatigue, which reduces their motivation and self-care abilities. Long-term complex rehabilitation programs improve all parameters of chronic fatigue, respiratory efficiency, and prognostic indicator of chronic heart failure--ventilatory equivalent for carbon dioxide.

Exercise training after coronary angioplasty improves cardiorespiratory function

AIM

The aim of this prospective randomized study was to evaluate the impact of long-term aerobic exercise training on respiratory function, left ventricular systolic function and remodeling in patients with coronary heart disease and ischemic heart failure after successful angioplasty.

DESIGN

Patients (n=185) have undergone Doppler echocardiography and ergospirometry. Ninety-five patients practiced 6 month-term aerobic exercise training, less by 10% to their anaerobic threshold. Ninety patients were studied as controls. They were given only drug treatment without training. Measurements were repeated after 6 and 12 months.

RESULTS

Training group patients after 6 months showed significant (p<0.05) improvement in exercise capacity, oxygen consumption and ventilating equivalents. The Doppler echocardiographic findings revealed significant (p<0.05) improvement in ejection fraction, left ventricular and atria morphometric data. Improved ergospirometric and echocardiographic data were established after 12 months, too.

CONCLUSIONS

Long-term aerobic exercise training is an effective and workable measure improving respiratory efficiency, left ventricular systolic function, attenuating negative remodeling and stopping further progression in patients with coronary heart disease and chronic heart failure after successful angioplasty.

Development of structural cardiac adaptation in basketball players

BACKGROUND

As specific features of the basketball player's myocardial structure and function are still rather poorly investigated, we aimed at comparing left ventricular (LV) echocardiographic indices in players of different age groups.

METHODS

Male basketball players aged 8-13 years (n=31), 14-17 years (n=31) and 18-28 years (n=31) were examined using standard echocardiography. End-diastolic LV posterior wall thickness and internal diameter, as well as interventricular septum thickness, were measured by M-mode. Relative wall thickness was calculated by dividing the sum of the thicknesses of the interventricular septum and LV posterior wall by LV internal diameter. LV mass and ejection fraction were also calculated. The morphological LV parameters were corrected for body surface area. The peak early (E) and peak late (A) transmitral flow velocities were measured using pulsed Doppler, and the ratio (E/A) was calculated.

RESULTS

Significant differences in the absolute internal LV diameter among the age groups disappeared after allometric scaling. However, relative wall thickness as well as body size indexed LV posterior wall thickness and LV mass were significantly greater in the adolescents and adults than in the children. Players of different age groups did not differ in the E/A ratio, while ejection fraction was elevated in adolescents.

CONCLUSIONS

Regular basketball training results in moderate cardiac hypertrophy in adolescents and adult athletes due to thickening of myocardial walls.

[Left ventricular remodeling in ischemic heart disease patients with signs and symptoms of chronic heart failure: an impact of the long-term exercise training]

Our study aimed at determining the effects of long-term exercise training on cardiorespiratory function and left ventricular remodeling in ischemic heart disease patients with the evidence of chronic heart failure, who had undergone a successful coronary angioplasty. One hundred thirty-five patients were entered into one-year study: 70 patients were assigned to the long-term exercise training group, and the remaining 65 persons--to the control group. All the patients were subjected to ergospirometry and echocardiography at study entry and at 6 and 12 months. At the outset, both groups showed no significant difference (P>0.05) in terms of ergospirometry findings. However, after 6 months, the rehabilitation group demonstrated significant changes (P<0.05) in exercise time, double product, RQ, AT VO2, VE/VO2, while the control group displayed no significant changes. After 12 months, the patients of rehabilitation group showed further increase in exercise time (from 5.6+/-1.9 min to 6.5+/-2.1 min) and AT VO2 (from 17.3+/-7.2 ml/kg/min to 20.8+/-5.4 ml/kg/min) indices (P<0.05). Those of double product and VE/VO2 decreased slightly when compared with findings at 6 months. RQ remained virtually at the same level, but significantly differed from the corresponding indices at the outset. Echocardiography performed at the entry and at 6 and 12 months revealed significant changes in systolic left ventricular function among the patients of rehabilitation group: wall movement index, ejection fraction as well as the left atrial long axis and left ventricular wall thickness. Echocardiographic changes indicate a positive impact of complex rehabilitative measures on systolic left ventricular function as evidenced by the ejection fraction and wall movement index values, as well as by regression of left ventricular wall thickness and left atrial long axis. Ergospirometry findings allow us to propose that the adequate choice of rehabilitative tools favorably affects the cardiovascular system, and this is reflected in exercise time and AT VO2 indices.

[Chronic fatigue syndrome in cardiology neurohumoral changes]

Chronic fatigue markedly worsens quality of life of cardiological patients. Chronic fatigue and chronic fatigue syndrome are neuro-immuno-endocrine disorders which manifest as moderate and severe even invalidizing fatigue with psychosomatic symptoms. External and internal stress such as psychological stress, stress after major surgery and trauma, depressive states, inadequate physical exercise, chronic heart failure, chronic viral infection, oncologic diseases, -- can promote development of chronic fatigue. Immune and hypothalamic-pituitary-adrenal (HPA) axis abnormalities were found to be associated with this condition. Measurement of plasma cortisol concentration is used as basic characteristic of HPA axis function. Measures aimed at detection of chronic fatigue in cardiological patients and its appropriate management should supplement programs of integrated rehabilitation in order to improve quality of life and facilitate return to work.

[Spiroveloergometry parameters and parameters of blood gases and acid-base equilibrium at rest and during exercise in athletes]

The aim of the study was to evaluate spiroveloergometric and blood gases data and compare them among swimmers and basketball players. Examinations were performed for swimmers and basketball players (n=85). Spirometry at rest and spiroveloergometry, analysis of blood gases and acid-base equilibrium at rest and during exercise were performed. Minute ventiliation of swimmers at rest was statistically significantly (p<0.001) lower than of basketball players: 11.0 l/min and 22.1 l/min correspondingly. Partial pressure of blood carbon dioxide for swimmers was larger, than of basketball players (41.5 and 35.9 mm Hg correspondingly, p<0.001), plasma bicarbonates as well (25.2 and 22.5 mmol/l, p<0.01) and there was no bases excess (BE -0.22 and -2.95, p<0.001). Spiroveloergometry showed, that at the same minute ventiliation and the same work level oxygen metabolic units (MET) were significantly (p<0.001) larger for swimmers: 21.2 and 14.9 correspondingly. Decompensated metabolic acidosis during maximal exercise for swimmers was not determined.

CONCLUSIONS

swimmers' ventilation was more economic than of basketball players, oxygen consumption and aerobic capacity were statistically significantly better.

Ikirara insertions reveal five new Anopheles gambiae transposable elements in islands of repetitious sequence

Characterization of Anopheles gambiae genomic clones containing Ikirara inverted repeats revealed five novel sequences related to known transposable elements (TEs). One TE is related to the mariner/Tc1 superfamily of class II (DNA-to-DNA) transposons, while four are related to class I (RNA-mediated transposition) elements. Crusoe, the class II element; is most similar to the Caenorhabditis elegans transposon Tc1-like TEs. Vash elements, represented twice in our clones, are related to the Q/T1 family of A. gambiae non-LTR retrotransposable elements. Guildenstern is a member of the RT1 and RT2 non-LTR retrotransposon family. Although RT1 and RT2 elements normally have a highly stereotyped insertion preference for sequences within ribosomal genes, Guildenstern is not located in ribosomal sequence. JuanAg is the first anopheline member of the mosquito non-LTR retrotransposon family of Juan elements that previously had included just the culicine elements JuanA and JuanC. Approximately 753 bp is missing from the central portion of the JuanAg reverse transcriptase gene, where an Ikirara inverted repeat is found in its stead. Ozymandias, the only LTR retrotransposon found in the clones, is most similar to the Drosophila melanogaster 412 element. Single Ikirara inverted repeats were also found adjacent to nontransposable element repetitious sequences. Our analysis suggests that the A. gambiae genome organization could best be described as islands of short-period interspersion repetitious DNA in a sea of long-period interspersion, mostly unique sequence DNA.

Expression of mouse HES-6, a new member of the Hairy/Enhancer of split family of bHLH transcription factors

We studied the expression of mouse HES-6, a new member of the Hairy/Enhancer of split family of basic helix-loop-helix transcription factors. HES-6 is expressed in all neurogenic placodes and their derivatives and in the brain, where it is patterned along both the anteroposterior and dorsoventral axes. HES-6 is also expressed in the trunk, in the dorsal root ganglia and in the myotomes. In the limb buds HES-6 is expressed in skeletal muscle and presumptive tendons.

Segmentation: a view from the border

Segmentation, or metamerism, consists of the subdivision of the body into discrete units that subsequently acquire regional specializations. In vertebrates, the most obvious manifestation of this phenomenon is seen during the formation of the mesodermal somites and their derivatives. This review surveys three different models for how somites form, and how they relate to recent molecular data suggesting the involvement of transcription factors and cell surface molecules. A new model (the "Morse code" model) is proposed to convey positional information to somitogenic cells. Finally, the molecular events of boundary formation (during the initial epithelialization of somites) and boundary maintenance (between adjacent somite halves as well as in resegmentation) are discussed.

SWiP-1: novel SOCS box containing WD-protein regulated by signalling centres and by Shh during development

We describe a novel chick WD-protein, cSWiP-1, expressed in somitic mesoderm and developing limb buds as well as in other embryonic structures where Hedgehog signalling has been shown to play a role. Using embryonic manipulations we show that in somites cSWiP-1 expression integrates two signals originating from structures adjacent to the segmental mesoderm: a positive signal from the notochord and a negative signal from intermediate and/or lateral mesoderm. In explant cultures of somitic mesoderm, Shh protein induces cSWiP-1, while a blocking antibody to Shh inhibits the induction of cSWiP-1 by the notochord. These results show that the positive signal from the notochord is mediated by Shh. We also show that in limb buds cSWiP-1 is upregulated by ectopic Shh. This occurs in about the same time period as upregulation of BMP2, placing cSWiP-1 among the earliest markers for the change of limb pattern caused by ectopic Shh. We also describe a human homologue of cSWiP-1 and a mouse gene, mSWiP-2, that is more distantly related to SWiP-1, suggesting that SWiP-1 belongs to a novel subfamily of WD-proteins.

Use of coronary angiography and revascularization procedures following acute myocardial infarction. A European perspective

AIMS

There is little evidence to inform routine practice in the use of coronary angiography and revascularization procedures after acute myocardial infarction. Large differences in the uptake of these procedures have been reported but representative data are scarce. Outcome studies have produced opposing conclusions concerning the impact of the high rate of these cardiac procedures.

METHODS AND RESULTS

A population-based patient sampling approach was utilized to identify routine practice in representative samples from 11 European countries. Data were collected retrospectively on treatment in the 6 months following acute myocardial infarction (n=2807). There was wide variation in utilization of coronary angiography and revascularization procedures. Even after restricting the analysis to patients <65 years (n=1262), there remained a 6 13 fold variation in the use of these procedures. A decreased likelihood of undergoing these procedures was associated with older age. In addition, there was an independent and negative association between female sex and utilization of coronary angiography and coronary artery bypass grafting (CABG).

CONCLUSION

The effect on patient outcome of the observed variation in use of these procedures is not known but has important cost and resource implications for the health services. Outcome research is needed to define patient selection criteria and to measure the cost-utility of different angiography and revascularization rates.

Clocked gene expression in somite formation

A recent paper describes a striking expression pattern during somite formation for a chick ortholog of the fly hairy gene. Before segmentation, c-hairy1 mRNA oscillates in the presomitic mesoderm such that three distinct spatial patterns are seen. The authors use a series of ingenious manipulations to show that these phases follow each other in time, adding up to a 90-minute periodicity in c-hairy1 expression. The discovery of this clock of gene expression emphasizes the importance of temporally regulated events in the establishment of spatial patterns.

Beta-blockers and antithrombotic treatment for secondary prevention after acute myocardial infarction. Towards an understanding of factors influencing clinical practice. The European Secondary Prevention Study Group

AIMS

Long-term beta-blockade reduced mortality after acute myocardial infarction by about a quarter in a series of published trials. Representative data on beta-blocker use for secondary prevention are scanty but indicate wide variations. We have analysed European practice, and sources of variation, by regional sampling of acute myocardial infarction patients admitted to hospital in 11 countries during the period January 1993-June 1994.

METHODS AND RESULTS

Treatment data for 4035 representative patients were collected for the hospital phase and 6 months after discharge. A logistic regression model was developed to describe the predictors of beta-blocker use. In the 11 regional samples, 6-38% (20% overall) of patients had no recorded contraindications but were discharged without a beta-blocker. In the absence of perceived contraindications, there was a strong, independent negative association between age and odds of treatment (P < 0.001), and women were less likely to be treated than men (adjusted odds ratio 0.76, 95% CI 0.58-0.99). Discontinuation of beta-blocker treatment by 6 months was significantly less likely in regions where the proportion given such treatment at discharge was high. In contrast, use of antithrombotic agents in the samples was consistently high.

CONCLUSIONS

There is persisting low use of beta-blocker secondary prophylaxis, particularly in the elderly and in women, not attributable to perceived contraindications or intolerance. Considerable regional variations persist despite shared trials evidence. Discharge treatment strongly influences long-term medication.